Heico-Rüdiger Krause

The innervation of the trapezius muscle in connection with radical neck-dissection. An anatomical study.

The accessory nerve, the cervical plexus, the sternocleidomastoid and trapezius muscles and neighbouring structures were examined in 47 corpses. Considerable inter- as well as intra-individual differences could be found both in the course and shape of the accessory nerve and in the participation of the cervical plexus in the innervation of the trapezius muscle. The great variation in the manifestation of the shoulder-arm-syndrome in patients after radical neck-dissection can thus be explained. Finally a new method of restoring the innervation of the trapezius muscle is proposed.

A technique for diagnosing the individual patterns of innervation of the trapezius muscle prior to neck dissection

Based on the techniques of regional anaesthesia, a method for simulating the effects of radical neck dissection on the innervation of the trapezius muscle by selectively and reversibly blocking the accessory nerve and its superficial cervical anastomoses, was developed and tested on 40 patients who were due to undergo radical neck dissection. Action potentials of the three portions of the muscle were recorded after this blockade as well as after radical neck dissection, and compared. It was found that the electromyograms were congruent in 92.5% of the cases. Four patterns of innervation were demonstrated, ranging from complete substitution of the resected or blocked nerves to a remaining muscle activity of less than 20% after blockade or radical neck dissection.

Reinnervation of the trapezius muscle after radical neck dissection

Based on the observation, that the caudal parts of the trapezius muscle after radical neck dissection with complete loss of the spinal accessory nerve, are still innervated to an individually varying degree, and on recent anatomical findings relating to this fact, a method for completely reinnervating the trapezius muscle, despite uncompromising radicality of the dissection, is introduced. This procedure consists of identifying and dislodging a subfascial branch of the deep cervical plexus running to the caudal parts of the trapezius muscle in the lateral cervical triangle and anastomosing it to the distal stump of the accessory nerve, using microsurgical techniques, thereby connecting it to the whole innervation system of the muscle. Clinical and electromyographical examinations showed very good recovery of all three portions of the muscle, 15 months after the procedure, in 46 of 52 patients (85%), although these patients were preselected by temporarily blocking the accessory nerve prior to operation, as possessing very little additional nerve supply.

The behaviour of neurogenic tumours of the maxillofacial region

In 37 patients with neurogenic tumours of the maxillofacial region, epidemiology, clinical, sonographical and computer tomographical findings as well as the results of fine needle aspiration cytology (FNAC), histopathological evaluation of biopsies and flow cytometric determination of DNA ploidy, were analyzed in order to detect characteristics distinguishing the behaviour of the neoplasm prior to resection. Simultaneous histopathological and flow cytometric evaluation of biopsies is recommended to avoid the danger of mistaking ancient schwannomas for malignancies and vice versa. FNAC proved to be unreliable in these cases. The retromaxillary/pterygomandibular region appeared to be the most likely site for malignant schwannoma. Von Recklinghausens neurofibromatosis in the patient or in their family should lead to immediate investigation of any mass developing in the vicinity of the facial or trigeminal nerves.

Assoziierte Anomalien bei Lippen-Kiefer-Gaumen-Spalten

Fragestellung. Die Diagnose von Lippen-Kiefer-Gaumen-Spalten verweist auf kein uniformes Krankheitsbild, sondern spiegelt das Resultat eines multifaktoriellen heterogenen Geschehens wider. Als Ausdruck dessen werden in der Literatur bei Spaltträgern die Häufigkeiten assoziierter Anomalien unterschiedlich angegeben. Patientengut. In einem Zeitraum von 1974–1998 wurden retrospektiv 1737 in der Klinik behandelte Patienten mit Spaltbildungen im Gesichtsbereich auf zusätzliche Fehlbildungen und Syndrome hin untersucht. Ergebnisse. Bei 33% der Spaltträger zeigten sich assoziierte Anomalien, von denen 48% bekannten Syndromen zugeordnet werden konnten. Patienten mit isolierten Gaumenspalten (45,6%) und mit doppelseitiger LKG-Spalte (35,3%) waren besonders häufig von zusätzlichen Fehlbildungen betroffen. Hohe Manifestationsraten ergaben sich hierbei für zerebrale Störungen (16%), zusätzliche Gesichtsfehlbildungen (14%), Herzfehler (13%), Extremitätenfehlbildungen (9%) und urogenitale ¶Anomalien (8%). Stoffwechselerkrankungen traten hingegen selten auf (0,5%), ein partieller Situs inversus war in nur 1 Fall zu diagnostizieren. Schlussfolgerung. Die hohe Koinzidenz von Fehlbildungen mit Lippen-Kiefer-Gaumen-Spalten unterstreicht den Stellenwert des umfangreichen interdisziplinären Neugeborenenscreenings bei Spaltträgern in unserer Klinik. Background. Retrospective studies of cleft lip and palate patients suggest a multifactorial aetiology for this condition. Many patients exhibit multiple defects, often removed from the orofacial region. The frequency and location of such coexistent abnormalities vary between studies. Patients. A retrospective case-note study of 1,737 individuals with orofacial cleft, treated between 1974 and 1998 at our centre, was undertaken to assess the frequency of associated malformations and syndromes. Results. Associated malformations were found to be present in 33% of all cases investigated. In nearly one half of these individuals (48%), defects could be attributed to recognisable syndromes. Patients with isolated palatal clefts (45.6%) and those with bilateral clefts of the lip and palate (35.3%) were particularly well-represented. The following problems were observed relatively frequently: Cerebral anomalies (16%), facial anomalies (14%), heart malformations (15%), anomalies of the extremities (9%) and urogenital tract abnormalities (8%). In contrast, endocrine aberrations were identified sporadically (0.5%). A partial situs inversus was found only in one case. Conclusion. As clefts of the lip and palate are frequently associated with additional malformations, the importance of thorough interdisciplinary neonatal screening cannot be over emphasised.

Methoden der Schmerztherapie in der Mund-, Kiefer- und Gesichtschirurgie

Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.Schmerztherapie im Mund-, Kiefer- und Gesichtsbereich bereitet immer noch häufig Probleme. Vor Einleitung einer Therapie ist daher die Schmerzgenese sorgfältig abzuklären. Neben der Darstellung der wichtigsten Krankheitsbilder werden diagnostische und differenzialdiagnostische Aspekte sowie Therapieschemen dargestellt. Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.

A strategy to avoid facial mutilation in orbital embryonal rhabdomyosarcoma

IntroductionAn orbital embryonal rhabdomyosarcoma (RMS) is a rare malignancy in children, but clinical findings are typical. We detail the case of an 8-year-old female with orbital RMS and discuss the therapeutic options.Case reportOrbital RMS was apparent with painless exophthalmos of the right globe and diplopia. Head MRI showed tumor masses behind and inferior to the globe. Open biopsy led to the histological diagnosis. Metastasis or infiltration of orbital bone was not observed. Chemotherapy was carried out in accordance with the Cooperative Weichteilsarkom Studie (CWS) 2002 protocol. Tumor regression was detected after the first course of chemotherapy; we decided to excise the residual tumor with preservation of the globe. The CWS 2002 protocol was subsequently completed. Radiotherapy was not done. One year after treatment, RMS recurrence was not observed.ConclusionAfter interdisciplinary treatment, mutilation was avoided after exenteration of the orbit or radiation treatment to the growing facial skeleton. That was possible due to excision of the residual tumor in a second step, leading to down-staging of the RMS.

Methods of pain therapy in oral and maxillofacial surgery

Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.Schmerztherapie im Mund-, Kiefer- und Gesichtsbereich bereitet immer noch häufig Probleme. Vor Einleitung einer Therapie ist daher die Schmerzgenese sorgfältig abzuklären. Neben der Darstellung der wichtigsten Krankheitsbilder werden diagnostische und differenzialdiagnostische Aspekte sowie Therapieschemen dargestellt. Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.

Methoden der Schmerztherapie in der Mund-, Kiefer- und Gesichtschirurgie@@@Methods of pain therapy in oral and maxillofacial surgery

Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.Schmerztherapie im Mund-, Kiefer- und Gesichtsbereich bereitet immer noch häufig Probleme. Vor Einleitung einer Therapie ist daher die Schmerzgenese sorgfältig abzuklären. Neben der Darstellung der wichtigsten Krankheitsbilder werden diagnostische und differenzialdiagnostische Aspekte sowie Therapieschemen dargestellt. Pain therapy in the oral and maxillofacial region is still a problem. Before starting therapy, the genesis of pain has to be carefully clarified. The article presents the most important syndromes, aspects concerning diagnosis and differential diagnosis as well as therapeutic schemata.